REVIEW Open Access
Type D personality in the general population: a
systematic review of health status, mechanisms
of disease, and work-related problems
Floortje Mols
*
, Johan Denollet
Abstract
Background: The objective was to review all available literature concerning Type D (distressed) personality among
the general population and to discuss its implications for research on health status, disease-promoting me chanisms
and work-related problems in non-clinical populations.
Methods: A computerized search of the literature was performed independently and in duplicate by both
investigators on December 21
st
, 2009. Published research reports were included if they studied Type D personality
among the general population. Nineteen articles were selected and they were subjected to an 11-item
standardised quality checklist by both investigators.
Results: The methodological quality of the selected studies was adequate to high. The studies included in this
review showed that the presence of Type D characteristics had a negative impact on mental health status (more
symptoms of depression, anxiety, post-traumatic stress disorder, mental distress, passive coping, and less social
support) and physical health status (more somatic complaints, lower health status, more influenza-like illness
reporting). Other studies reported on behavioral and biological mechanisms of disease in apparently healthy
individuals with a Type D personality. Finally, some studies also showed a negative effect of Type D personality on
work-related problems (higher absence-leave, highe r levels of vital exhaustion and burnout, and more work-related
stress).
Conclusions: Type D personality is a vulnerability factor for general psychological distress that affects mental and
physical health status and is associated with disease-promoting mechanisms and work-related problems in
apparently healthy individuals.
Introduction
In the past decade, studies on the effects of Type D per-
sonality on clinical and psychological outcomes have

reproduction in any medium , provided the original work is properly cited.
social inhibition correlated negatively with conscien-
tiousness [1].
ThemajorityofstudiesonTypeDpersonalityhave
focused on its prevalence and effects in patients with a
variety of cardiovascular diseases since the Type D
construct was originally described and further devel-
oped in this patient group [3]. These studies in cardio-
vascular patients have show n that Type D personality
is an independent predictor of negative health out-
comes such as poor health status, (recurrent) myocar-
dial infarction, and increased risk of mortality [4-7].
Given the clinical relevance of findings on Type D
research in the context of cardiovascular disorders, it
is also important to assess the potential relevance of
the Type D construct among apparently h ealthy people
from the general population.
Although Type D personality has been shown to pre-
dict cardiac prognosis after adjustment for clinical mar-
kers of disease severity [4,7], there still is a possibility
that markers of disease severity that were not controlled
for might have led t o the occurrence of Type D charac-
teristics in these studies. Studying Type D personality in
apparently healthy people from the general population
wouldprovideamoredirecttestofthenotionthat
Type D is not an epiphenomenon caused by cardiovas-
cular disorder. Moreover, Type D personality is based
on normal personality traits rather than p sychopathol-
ogy which implies that it should be prevalent in the gen-
eral population as well [1], and that it may have an

etc.), (3) if they were published in peer-review journals,
and (4) if they were written in English. Studies were
excluded for the following reasons; (1) if they included a
patient population, and (2) if they only reported results
on negative affectivity or social inhibition instead of
Type D. The literature search wa s conducted indepen-
dently and in duplicate by both investigators.
The described inclusion and exclusion criteria were
applied to our initial 567 hits. Based on their titles and
abstracts 21 articles met our criteria. These studies were
conducted between 2002 and 2009. Hard copies were
obtained of 21 studies and were reviewed by both investi-
gators. After careful review, 19 articles fulfilled our selec-
tion criteria and were included in this review [8-26]. A
flow-chart of this selection procedure is shown in Figure 1.
Quality assessment
The methodological quality of each of the selected arti-
cles was assessed with an 11-item standardised checklist
of predefined criteria by both investigators. The check-
list was based on established criteria lists for systematic
reviews [27,28]. The criteria are presented in Table 1.
Each item of a selected study, that matched our cri-
teria, received one point. If an item did not meet our
criteria or was described insufficiently or not at all, zero
points were assigned. The highest possible score was
thus 11. Studies scoring 75% or more of the maximum
attainable score (= 8 points) were arbitrarily considered
to be of ‘high quality’. Studies scoring between 50% and
75% (6-7 points) were rated as ‘adequate quality’. Studies
scoring lower then 50% (i.e. <6 points) were considered

studies. The lowest mean age was 10.7 [13] and the
highest was 54.2 [23]. Most studies included both males
and females.
The most frequently used q uestionnaire to determine
Type D personality was the 14-item DS14 scale
[8,10,12,14,17-21,23-26]. In the other studies the DS16
[16,22] or DS2 4 [9,11] scales were used. One study
assessed social inhibition with the social avoidance and
distress items of the Social Anxiety Scale for Children
andusedtheChildren’s Depression I nventory to assess
negative affect [13]. Another study assessed Type D by a
combination of the Amsterdam Biographical Question-
naire, the Spielberger Trait Anxiety Inventory and the
Young Adult Self-Report [15]; after the combination of
scales method, 20 items were selected and used to
determine Type D status.
Whereas the majority of publications on Type D per-
sonality among patients with cardiovascular diseases ori-
ginate from the Center of Research on Psychology in
Somatic diseases (CoRPS) at Ti lburg University, the
Netherlands, only 6 studies in the present review origi-
nated from CoRPS and 13 studies on Type D in the
general population were performed by other research
groups. The studies were conducted in populations from
8 different countr ies: Netherlands (n = 8), United King-
dom (n = 4), Belgium (n = 3), Germany (n = 2), Canada,
Ireland, Poland, and Ukraine.
The results of the studies included in this review are
first described below according to the impact of Type D
personality on m ental and physical health status (Table

potential applicable. Hard copies were
obtained for more detailed evaluation of our selection
criteria.
After applying our selection criteria to the hard copies, 19
articles were selected and were finally included in this
review.
548 articles excluded due to selection
criteria and removal of duplicate articles*
Computerised search of databases and reference checking.
567 hits
Figure 1 Flow diagram of papers accepted and rejected during selection procedure. * The selection criteria are described in the methods
section.
Mols and Denollet Health and Quality of Life Outcomes 2010, 8:9
/>Page 3 of 10
more likely to let things get them down compared to
non-Type Ds [26].
Six studies reported results on the effect of Type D
personality on physical health status (Table 3 - section
b). Children with a Type D personality reported more
somatic complaints (24 vs. 18; p < 0.05) compared to
non-Type D children [13]. Adult men and women with
aTypeDpersonalityalsoreportedasignificantlylower
health status compared to non-Type D’s [9,23]. Another
study reported that negative affectivity was associated
with more influenza-like illness reporting while social
inhibition was associated with less influenza-like illness
reporting [21]. Finally, female teachers with a Type D
personalityweremorebotheredbytheirvoicecom-
plaints [22] and reported a higher biopsychosocial
impact of their voice complaints [16] than their non-

system, emotion-processing in the brain, and heritability.
Men with a Type D personality, but not women, exhib-
ited higher cardiac output d uring experimental stress
compared to non-Type D men [25]. Another study
showed that socially inhibited men had heightened sys-
tolic and diastolic blood pressure reactivity, while nega-
tive affectivity was related to dampened heart rate
reactivity [11]. Type D was also associated with a differ-
ential activity of the amygdala in react ion to fearful ver-
sus neutral fa ce and body expressions. Emotion-evoked
activation of the amygdala was present in non-Type D’s
but was absent in Type D individuals [10]. F inally, evi-
dence suggests that Type D personality may be substan-
tially heritable; heritability has been estimated to be 52%
[15]. Heritability for negative affectivity was 46% due to
additive genetic factors, while heritability for social inhi-
bition was 50% due to nonadditive or dominance genetic
effects [15].
Type D personality and work-related problems
Associations between Type D personality and impaired
health status may also have an impact on health pro-
blems in the occupational setting. Four studies reported
that a Type D personality was associated with work-
related problems (Table 4 - section b). With reference
to this issue, Type D personality has been associated
with effort-reward imbalance, overcommitment, per-
ceived adverse physical working conditions, and sub-
stantial problems in interactions with s upervisors and
co-workers [12]. Importantly, this study also showed
Table 1 List of criteria for assessing the methodological

Mols and Denollet Health and Quality of Life Outcomes 2010, 8:9
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Table 2 Characteristics of studies*
Study Country Size
sample
Participants Mean age in
years
Sex % Type
D
Design Research
group
Study
quality
[8] U.K. 564 British males M = 26.2
R = 18-55
564 men 29% Cross-
sectional
Other 8
[9] Belgium 155 policemen and nurses M = 32
R = 20 - 56
66 men
85 women
35.5% Cross-
sectional
CoRPS 7
[10] Netherlands 17 right-handed men M = 23
SD = 2.4
17 men
no women
23.5% Cross-

women
26.7% Cross-
sectional
CoRPS 8
[16] Netherlands 755 student teachers M = 18.8
R = 16-29
No men
755
women
25.9% Cross-
sectional
Other 9
[17] Poland 79 psychiatrists and
nurses
M = 39.7
S = 8.2
25 men
28 women
27.8% Cross-
sectional
Other 6
[18] Ukraine 250 university students M = 20.9
SD = 3.4
113 men
137
women
22.4% Prospective CoRPS 9
[19] U.K. 334 university students M = 19.5
R = 18-41
180 men

[23] Netherlands 622 adults M = 54.2
SD = 14
318 men
304
women
18.1% Cross-
sectional
CoRPS 8
[24] Belgium 132 adults M = 33.7
SD = 14.5
70 men
57 women
Unknown Cross-
sectional
Other 9
[25] U.K. 84 adults M = 22.0
SD = 6.8
42 men
42 women
Unknown Prospective Other 9
[26] U.K./Ireland 1012 adults M = 20.5
SD = 4.8
225 men
787
women
38.5% Cross-
sectional
Other 8
* In alphabetical order
R = range; SD = standard deviation; IQR = interquartile range; CoRPS = Center of Research on Psychology in Somatic Diseases; Other = other research group not

tal health problems in Type D individuals was also
found in chronic pain patients [36], diabetes patients
[37], and cardiac patients [38]. Furthermo re, the studies
included in this review showed that people with a Type
D personality more often reported mental health disor-
ders [17] as well as lower levels of social support [26]
compared to non-Type D adults.
ThepresenceofTypeDpersonalityamongpeople
from the general population was also associated with a
poor physical health status. For example, Type D’ s
reported more somatic complaints [13,16,22] and a sig-
nificantly lower hea lth status compared to non-Type D’s
[9,23]. This is in line with the adverse effects of Type D
on somatic health status in cardiovascular conditions. In
patients with heart failure, it was found that Type D
personality was an independent predictor of impaired
health status [39] and more cardiac symptoms [40].
Also, Type D patients with heart failure were at 6-fold
increased risk of reporting impaired health status com-
pared to the reference gro up of non-Type D patients
[41]. Finally, Type D was a strong predictor of adverse
cardiac outcome after acute myocardial infarction, and
the associated risk was similar to that of traditio nal car-
diovascular risk factors [7].
Some studies that are included in this review explored
the behavioral and biological mechanisms of disease as a
Table 3 Outcomes of studies: Health status
Outcome Study Participants Conclusion
(3a) Mental
health

Type Ds.
[13] 668 children
(Netherlands)
Children with a Type D
personality reported more
negative mood states (10.43
vs. 6.96) and more non-
productive thoughts (10.15
vs. 5.13) than non-Type D
children.
[17] 79
psychiatrists
and nurses
(Poland)
Individuals with a Type D
personality manifested
significantly more symptoms
of mental health disorders
than non-Type D
individuals.
[24] 132 adults
(Belgium)
Type D individuals had
more symptoms of mental
distress (rs > .38) compared
to non-Type D; Type D has
a more adverse effect with
low levels of
authoritarianism (b = .62; p
< 0.01).

/>Page 6 of 10
function of Type D personality in apparently health
individuals. Hence, a poor physical health status can be
explained by the fact that Type D individuals perform
significantly fewer health-related behaviors (eat sensibly,
spend time outdoors, get a regular medical check-up)
[26] and that they are more likely to smoke [6] as com-
pared to no n-Type D individuals. Furthermore, two stu-
dies showed that individuals w ith a Type D personality
are less likely to seek appropriate medical care [22,26].
This has also been shown in Type D patients with
chronic heart failure causing a significant decrease in
health status among these patients [41,42].
The fact that Type D individuals tend to experience
interpersonal situations as being stressful may also have
direct biological effec ts that may impact on the cardio-
vascular system. Responding to these situations can eli-
cit physiological reactivityeverytimeapotentially
“threatening” situation is encountered [11]. Accordingly,
Type D was associated with increased cardiac output
[25], heightened systolic and diastolic blood pressure
reactivity [11], and dampened heart rate reactivity dur-
ing experimental stress. Type D was also associated with
a decreased activity in the amygdala in response to fear-
ful expressions [10], suggesting inadequate emotion-pro-
cessing in the brain. Finally, heritability might be an
underlying third variable that explains the co-occurrence
of disease and Type D personality through a shared
genetic c omponent that predispose people to both phy-
sical and psychological distress. In fact, Type D person-

accomplishment [17] than non-Type D’s. To our knowl-
edge, only one other study investigated the relationship
between work and Type D personality in patients with
an acute coronary syndrom, and found that failure to
resume work was not related to Type D personality [48].
This review has some limitations. The cross-sectional
nature of most studies (14 out of 19) did not allow us
to determine causal associations between Type D and
the studied outcomes. A prospect ive study might pro-
vide us with more answers about the exact relationship
between Type D personality and spe cific outcomes and
the extent o f this relationship. In addition, the studies
included in this review used a number of different ques-
tionnaires to assess Type D personality. Also, not all
studies used the correct method of calculating Type D.
Table 3: Outcomes of studies: Health status (Continued)
(3b) Physical
health
status
[13] 668 children
(Netherlands)
Children with a Type D
personality reported more
somatic complaints (24 vs.
18; p < 0.05) compare to
non-Type D children.
[23] 622 adults
(Netherlands)
Individuals with a Type D
personality reported a

complaints (10 vs. 7; p <
0.001) than their non-Type
D counterparts.
[16] 755 student
teachers
(Belgium and
Netherlands)
Type D student teachers
had a 4× greater risk of a
high Voice Handicap
Inventory score (rating the
subjective biopsychosocial
consequences caused by
voice problems) than the
non-Type D group.
Mols and Denollet Health and Quality of Life Outcomes 2010, 8:9
/>Page 7 of 10
Some studies claim to report on the effects of Type D
personality on health but only report on the effects of
social inhibition and negative affectivity on health. Stan-
dardisation of the use of valid Type D questionnaires is
essential f or adequate evaluation and mutual compari-
son of studies. Finally, one study reported on t he effect
of Type D personality in children [13]. Although the
results of this study were similar to the results found in
studies among adults, we need to be careful with draw-
ing conclusions on the association between personality
and health in children, since personality is likely to
change from childhood into adulthood.
This review also has some strengths. It is the first

ity is a vulnerability factor for general psychol ogical dis-
tress that may not only affect people with medical
conditions, but also affects the health status of
Table 4 Outcomes of studies: Medical and occupational setting
Outcome Study Participants Conclusion
(4a) Medical:
mechanisms of
disease
[22] 932 female teachers
(Belgium and Netherlands)
Female teachers with a Type D personality were significantly less likely to get
treatment for their voice complaints than their non-Type D counterparts (25.7%
vs. 39.3%; p = 0.016).
[26] 1012 adults
(U.K. and Ireland)
Type D individuals had fewer regular medical checkups (p = 0.027), and were less
likely to eat sensibly (p = 0.033) or to spend time outdoors (p < 0.001) compared
to non-Type Ds.
[8] 564 males
(U.K.)
Body dissatisfaction is more prevalent in Type D’s or in men who are sedentary.
The interaction between Type D and being sedentary is detrimental because it
can influence health risk behaviors
[25] 84 adults
(U.K.)
Men with a Type D personality, but not women, exhibited higher cardiac output
during experimental stress compared to non-Type D men (F[3,37] = 3.4; p <
0.05).
[11] 173 university students
(Canada)

(Netherlands)
Type Ds were more at risk for post-traumatic stress disorder than non-Type Ds (OR
9.09; 95%CI = 2.1-39.1; p < 0.005); this risk increased when exposed to inmate
aggression.
Mols and Denollet Health and Quality of Life Outcomes 2010, 8:9
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individuals from the general population. This review
thereby provides evidence that Type D personality is not
just a state of mind that people develo p in reaction to
the diagnosis of a medical condition, but rather repre-
sents a broad personality co nstruct that is prevalent in a
large subgroup of the general population. Consequently,
it may be an important vulnerability factor to assess in
future studies on work-related problems and mental and
somatic health status in the general population.
Abbreviations
(CoRPS): Center of Research on Psychology in Somatic diseases.
Acknowledgements
This work was supported by a VICI grant [#453-04-004] from the Netherlands
Organization for Scientific Research (The Hague, The Netherlands) awarded
to Johan Denollet.
Authors’ contributions
The concept of this review was designed by JD. After that, both authors
reviewed the available literature and checked the quality of the articles that
were included in this review. FM wrote the first draft of this paper and JD
supervised the writing process. Both authors approved the final version of
this manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 October 2009

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doi:10.1186/1477-7525-8-9
Cite this article as: Mols and Denollet: Type D personality in the general
population: a systematic review of health status, mechanisms of
disease, and work-related problems. Health and Quality of Life Outcomes
2010 8:9.
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